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Closing 5mm trocar holes

Discussion in 'Surgery and Surgical Subspecialties' started by filter07, Apr 1, 2012.

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  1. filter07

    filter07

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    Kind of trivial topic, but...What do you do for these?

    At my med school we used to just pinch and use glue.
    During residency I've seen a few ways with monocryl...
    1. Single buried suture
    2. Single horizontal mattress
    3. Untied Subcuticular suture with ends cut after glue

    I tend to prefer the glue only option on fatter people with redundant skin and no tension, and if my attendings insist on suture I like the horizontal mattress.

    My least favorite is the buried suture because I can never get the edges to get close enough.
  2. tussy

    tussy Senior Member

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    I do the single inverted suture, however, you have to make sure your tails of the suture aren't crossed, otherwise the edges won't come together. I complete it with a steristip and tell the patients not to remove the steristrips for at least 2 weeks.
  3. SLUser11

    SLUser11 CRS

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    I close 5mm trocar incisions with an inverted subcuticular using a 4-0 monocryl, and I've been very happy with the short and long-term cosmetic outcomes. I do believe that dermabond is almost as good, although it's difficult to evert the edges with that.

    The main reason I don't do dermabond is because this is the medical student's time to shine. They look forward to closing those small incisions, and they put a lot of TLC into the closure...I'm not going to take that away from them.
  4. Dirt

    Dirt From the earth.

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    Most places I have been let me close with the single buried stitch, then throw dermabond over it so the patient doesn't see how bad it looks until they leave the hospital.
  5. Dysinthecasino

    Dysinthecasino Dyson

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    I've used both a single burried stitch and a SubQ with good results. I had some trouble with good approximation early on but realized that I when I throw my knots that if I pull the suture parallel with the incision I get good results. Early on I was pulling the knot tight by pulling the free ends perpendicular which always left me with a big gap for those pesky small trocar holes. Throw some tegaderm over that and even questionable technique looks decent, med students best friend so far.
  6. droliver

    droliver Moderator Emeritus

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    Keep in mind that each ampule of Dermabond is $27 and a Monocryl or Vicryl is about $7/pack (Nylon is ~ $4.75). Dermabond is a significant and unnecessary expense. Your fixed costs for procedures are going to be increasingly tracked, and you need to pay attention to these things. All methods for paying you in the future being discussed involve cost-sharing incentives that will penalize you for every cost involved in your procedures. Something to think about.
  7. Jambo1

    Jambo1

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    I started out using a single buried 4-0 , but lately have switched to a horizontal mattress, I feel like I get better purchase out of the suture in terms of wound closure and it removes the need to use dermabond excessively like droliver alluded to.
  8. filter07

    filter07

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    How much is mastosol and steristrip? That would work just as effectively, I would think.
  9. dpmd

    dpmd Relaxing

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    The single buried stitch is hard to get perfect but it is all in how much tissue you grab as you are turning your wrist. Too much or too little and it looks like crap. The horizontal mattress is ok as long as you place it well. Too much tissue and it bunches, too little and it isn't closed. I assume no one does something external (like an interrupted nylon) but why not. If it is just about not wanting to bring them back to take out the stitch what about a monocryl interrupted (we do this to close the stab incision for a tunneled dialysis cath to avoid any chance of catching the tube-when the inside absorbs the outside falls off, but I haven't tried it for a port site ever). As for the cost difference, I think you would have to take into account the difference in OR time. Closing plus dermabond would be more expensive obviously, but I wonder if dermabond only would save you enough OR time that the costs would even out? Or steri strip only for that matter (and do you really need the mastisol or benzoin? I use mastisol when I place steris in the OR because we have it nearby and it is habit, but when I use it elsewhere and don't want to find it I just use them plain and it seems to be fine as long as there isn't tension.
  10. SLUser11

    SLUser11 CRS

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    The secret to a good inverted subcuticular stitch is to make a large tissue purchase. Little wimpy bites lead to the figure-of-eight look. Also, I tend to take the dermal bite as close as I can to the surface without causing dimpling.

    My main issue with the "U-stitch" that I think you're describing is that the knot is at skin level, and patients are often irritated by this. They complain that it itches or feels weird. In general, since they can see it and can feel it, it generates more questions and more patient unhappiness. I also think the immediate cosmetic outcome is better with the buried stitch.

    droliver, as our main plastics contributor, I'd be interested to hear what you think about the longer-term cosmetic outcomes of these different closure methods (buried subcuticular, u-stitch, knots vs. knotless, dermabond, staples, simple prolenes). Does it make a difference, or do they all look the same in a few months?
  11. dpmd

    dpmd Relaxing

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    One of our plastics guys claims you could use staple to close the face even and it would look fine as long as you took the out soon enough (and had appropriate deep closure)
  12. SLUser11

    SLUser11 CRS

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    The OB/GYN literature would agree with this. They've shown similar short and long-term cosmetic outcomes when comparing staples to subcuticular stitches....but they also take their staples out way faster than we do.

    The Gyn literature has also shown a decreased rate of SSI when you close the subcutaneous fat (versus just fascia and skin). To be honest, I tend to ignore the OB/GYN literature....some of their stuff is a little off-the-wall.
  13. dpmd

    dpmd Relaxing

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    If we closed a layer in betwen fascia and skin then in theory we coud the staples out earlier (deep dermal, not sure actual sub q would help). For a outpt surg it would mean sooner f/u though for removal
  14. Dirt

    Dirt From the earth.

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    Yeah I was surprised to find this out when they took out my wife's staples on POD 3 after a C-section.
  15. SLUser11

    SLUser11 CRS

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    I think pfannenstiel incisions are more forgiving. Sure, there are more young healthy ladies getting c-sections than big abdominal operations, but little old ladies getting the TAH/BSO do well with the pfannies as well.

    Since starting fellowship, I've become a huge fan of the low-transverse incision. It can be used for specimen extraction or for hand-assist during Lap totals/sigmoids/LARs/pouches. If the case gets too tough laparoscopically, you can do the rectal dissection with an open technique through the pfannie as well. The scars look really nice and hide well.
  16. 45408

    45408 aw buddy

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    How about the pediatric surgery X-stitch? I don't know what it's actually called, but it's the deep-->superficial, deep-->superficial stitch that everts the edges.

    The flip side is that it might save you a minute or two in the OR, and I've been quoted a rate of $60/minute for OR time.

    Yeah, I've only done one general case through a Pfannenstiel, but I wish we had more use for it.
  17. droliver

    droliver Moderator Emeritus

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    That calculation for true costs is an exercise in theoretical bull**** in the real world, as that kind of productivity hit is impossible to quantify and makes assumptions about time management that don't really exist. Loses of small blocks of time are not really addable in a meaningful way to merely state that your gain/loss in productivity is just the sum of those events. If you can't show it on an invoice or balance sheet, it really doesn't exist to an administrator. Watch your OR director roll their eyes the next time you promise them some new toy will save them time and pay for themselves!

    ie..... your hypothetical 1-2 minutes per case (which is inaccurate IMO as by the time you have to wait for the glue to completely dry you've usually taken longer for a short suture and dressing to be applied) doesn't really produce a meaningful gain in OR or employee utilization at the end of the day the way hospital schedules and staffing shifts run. You're not going to save enough time from something like that to move the needle enough to do more cases in a day per room or require fewer hospital staff. The gains in time have to be independent events (as opposed to a bunch of little separate ones) with bigger chunks (10-20 mins) to materially affect your costs on a predictable basis.
  18. droliver

    droliver Moderator Emeritus

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    So much of what makes a good scar is out of your direct control (ie. location of an incision or a person's biologic propensity for inflammation) that I'm coming to peace with the idea that it's really not all in my hands.

    1. It's my impression that the smallest gauge absorbable suture (I usually use monocryl) you can get away with for dermal and subcuticular closures tends to scar better, presumably from less residual inflammation of the suture material.

    2. I like glue as a dressing after I've already closed things because they can shower immediately. I'm not really convinced it makes a scar better.

    3. staples are bad karma, and frequently produce a lot of hatch marks. About the only place they're preferable is on the scalp as it produces less scar alopecia then sutures. They're also a pain in the ass to take out, an important consideration in what you'll choose to put on a patient.

    4. braided absorbables (vicryl and dexon) scar worse when used for subcuticular closure as they cause more inflammation. They are fine for deeper dermal closure, but they will spit a lot more then monofilaments absorbable.

    5. steristrips/paper tape or silicone sheeting of incisions are really the only interventions that have much evidence they affect scarring much. Everything else (scar gaurd, mederma, etc...) is pretty soft evidence-wise. Paper tape is by far the cheapest material for this.
  19. dpmd

    dpmd Relaxing

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    I was on plastics shortly after my thyroidectomy so I asked for recs on my incision. He grabbed a roll of paper tape and cut me a little strip to cover it with. I sort of thought he was crazy until later when I realized how faint my scar was. Between that and a determination to avoid sun exposure there for a year (scarves became my friends) it kept me from having my typical hyperpigmented scar. Now I pass those tips on to my patients who ask or are having an incision on a noticeable place.
  20. SLUser11

    SLUser11 CRS

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    That's pretty interesting. Do we just put a piece of paper tape over the incision after suture closure (i.e. no dermabond)? Do we put any tension on it to bring the wound edges together? How long should it stay on there? Can it be replaced or reinforced if soiled?
  21. 45408

    45408 aw buddy

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    If you use Dermabond, isn't the patient being billed for the cost? As long as it's a reimbursable item, why is the manager going to give you grief?
  22. droliver

    droliver Moderator Emeritus

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    It's not a reimbursable item, but comes out of the global DRG payment they get. Everything is itemized for charges and they can track your supplies on cases. Hospitals already put pressure on us for supplies, dressings, trochars, implants etc... on a cost basis reflecting this.

    Coming soon, the whole idea of cost sharing b/w providers and hospitals is going to be coming down over how to split the lump sum (which will go to the hospital BTW). On planet earth, we're NOT going to get paid more for using less resources, but we WILL be penalized for using more. ie. using Dermabond will get you paid $X less as you fee is capitated before expenses.
  23. 45408

    45408 aw buddy

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    Are there any broad categories you can lump things into in terms of what is a reimbursable item and what is not? E.g., staplers are, PTFE graft is, but suture isn't.

    wish I were surprised...
  24. illixir

    illixir One

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    I'm a medical student, but in the OR, we would use the steri-strip rather than paper tape, I'm guessing because the first dressing is sterile. After leaving the OR, paper tape can be used because sterility is no longer a concern. I believe the whole point of this intervention is to take the tension off of the scar and be put onto the steri-strip or paper tape so that the scar doesn't widen. So you place the tape on one side and pull that over and tape to the other side so the tension of the scar in keeping the skin on either side together is now on the tape. My understanding from plastics rotations is this can be done for as long as up to 6 months or a year but is usually until the patient can tolerate. The ones that are better about this seem to have less scar widening and a better result, though of course not drastic due to all the other factors involved and I would guess this is probably why time is not spent to preach this for every incision. Of course it can be replaced or reinforced if soiled, I think the point is to have the tension off of the scar as much as possible during the initial time period so there is less widening and it remains faint.

    I would think if you put dermabond in the OR so the patient could go ahead and shower you would just start with the paper tape/steri-stripping whenever afterwards. I don't think I've seen steri-strip over dermabond ever. I don't think it'd be a problem but just because it doesn't seem like there was a point to the dermabond if you're going to still cover it.
  25. Fah-Q

    Fah-Q Senior Member

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    Taping a wound provides compression, which is good for scar reduction.

    I agree with droliver. Most of scarring is out of our control. A laparotomy incision will always look worse than a thyroidectomy incision. Skin thickness and mobility have much more do to with the final result than choice of suture.

    I'm an ENT and most of my incisions are on the face or neck and they usually look great. Occasionally, I'll get asked to remove something from the upper back or shoulders and those scars usually look terrible. It is not really because I'm such a great surgeon on the face and then suddenly a terrible surgeon on the upper back. The scar potential is just vastly different between say an upper blepharoplasty incision and mole excision from the shoulder.
  26. SLUser11

    SLUser11 CRS

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  27. mrblair020

    mrblair020

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    Where is the evidence that says a patient can't shower after being sutured as opposed to dermabond?
  28. 45408

    45408 aw buddy

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    I've heard that it takes 48 hours for the wound to epithelialize, so you don't want to be putting tap water in there before that.
  29. dpmd

    dpmd Relaxing

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    I have heard this, followed this, and taught this to other people but I have no real evidence that this is how things should be done. I'm thinking of all the times I have cut myself on accident and how I didn't hesitate to clean with soap and water immediately and ad lib afterward. The one time I was cut bad enough to need stitches though I kept that puppy dry for a while. Something about the foreign bodies sitting there that is worrisome I guess. I would like to see a study comparing a same day shower (with normal soap) versus waiting a couple of days. Some of my patients would really benefit from an early shower (or at least those around them would).
  30. 45408

    45408 aw buddy

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    It's different with an open wound though - you can definitely wash that. It's just like washing a lac on a trauma patient before you close it.
  31. Winged Scapula

    Winged Scapula Cougariffic! Administrator SDN Senior Moderator Lifetime Donor

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    :shrug: I got in trouble as a resident for letting patient shower like on POD #5.

    I and most of my PRS colleagues here allow patients to shower 24-48 hours post-op. So far we haven't seen an excess of infections/dehiscence etc from dreaded tap water getting into the incisions (which are typically covered with Proxi-strips).
  32. 45408

    45408 aw buddy

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    By POD #5, we're usually encouraging our patients to shower. I think 24-48 hours is probably our standard.
  33. Winged Scapula

    Winged Scapula Cougariffic! Administrator SDN Senior Moderator Lifetime Donor

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    I know...that attending was just a crazy bitch. Everyone else was POD #5 dressing down, shower. One, who was a Hopkins grad, insisted on POD #2.

    Its what I see in practice as well.
  34. blue2000

    blue2000 Senior Member

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    In residency, we took all dressings down POD 2 and left them open to air.

    In my PP now, the nurses where I work are used to changing the dressing on POD 2 to a sterile, waterproof dressing and showering patients after the new dressing is on. My wound infection rate is ridiculously low so maybe there is something to it.

    When I had a reconstructive surgery on my ear, initially the gs teaching nurse told me I wouldn't be able to wash my hair for FIVE days (I jokingly told my PD I wouldn't come back til I could wash my hair). I was delighted to wake up post op and have the plastics residents tell me I could was my hair the next day. Anectdotally, nothing bad happened.
  35. armybound

    armybound future urologist. Moderator Emeritus

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    sorry to resurrect the thread, but port incisions have really been frustrating me lately. I get very poor results when I try to start and finish a subcuticular the same way I would for a larger wound.

    when you guys say a single buried, do you mean a deep-superficial-superficial-deep type of stitch? and horizontal mattress, a proximal-distal-distal-proximal? if so, what do you do with the knot?

    I'm giving a lot of thought to just running in from the skin without tying and then dermabonding. it seems to be the act of tying that's causing me to lose my approximation.. of course I need to work on technique as well.
  36. Pir8DeacDoc

    Pir8DeacDoc Cerumen Extractor

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    When i was an intern I'd do a single buried stitch and some glue on the skin. Vicryl. Monocryl. PDS. Doesn't really matter. Don't do trocars much in my line of work now :)
  37. cpants

    cpants Member

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    This is my favorite way. In through the skin, out at the apex and throw a snap on the loose end. Run it subcuticularly with 2-4 stitches with the last one through the other apex and out the skin. Can proceed directly to the next port site and repeat (closing all the ports with one long stitch). Then hold gentle tension on the ends at each wound and apply dermabond and cut the ends at the skin. Alternatively can tape the cut ends to the skin with a steri.

    I like it because it's fast, waterproof, and you get perfect approximation with no bulky knots in the wound.
  38. southernIM

    southernIM

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    Yes, and yes

    The knot buries, particularly with the first stitch you're describing. That's why you start deep.

    Also acceptable, although personally I've found that takes longer and is unnecessary for a 5mm port.

    This is where everyone loses it at the beginner stage. The knot has to be snugged down fully on a buried stitch. What I recommend is after the first throw to give a firm tug parallel to the direction of the wound - this really ensures it snugs down; then I make the second throw in the same direction (so it's a slip knot) and repeat.

    Honestly you need to just have someone watch you do it and give some constructive feedback. It's tough to say exactly what the issue is without seeing. With a single buried 4-0 monocryl you should be able to make a 5mm port look damn near perfect.
  39. armybound

    armybound future urologist. Moderator Emeritus

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    appreciate all of the feedback, I'll definitely be trying these things out the next time we do a lap case.

    any advice for 10-12mm incisions? do a couple of interrupteds? or should I be better at starting and finishing with a regular subcuticular?
  40. SLUser11

    SLUser11 CRS

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    For a 12 mm port site, I typically use 2 inverted, interrupted subcuticular stitches with 4-0 monocryl...caprosyn since I switched hospitals. Running sutures seem kind of silly for a wound that short. I hope that helps.


    On a side note, I absolutely hate all Covidien/US Surgical sutures. I was spoiled with Ethicon for 8 years, and I've had a hard time adjusting.
  41. armybound

    armybound future urologist. Moderator Emeritus

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    It absolutely will help if I can convince my upper levels and attendings that I don't need to run the port sites ;) I love a nice running subcuticular on a long wound, but those small incisions are such a pain to deal with.
  42. LucidSplash

    LucidSplash Vac Ninja Extraordinaire

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    We tend to eschew laparoscopic retrieval bags unless there is a real mess (ie pus or spillage of bile) and even then sometimes some of my attendings don't use them. I prefer an interrupted subq for all the larger retrieval sites because it gives me the skeevies to use a running suture to close a site that had a nasty gallbladder or appendix pulled through it (or even a non-so-nasty one). I also don't like using dermabond on the umbilical/periumbilical site for similar reasons. The 5 sites all close fine with a single inverted suture.
  43. SLUser11

    SLUser11 CRS

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    I can't be sure, but I don't think I've ever seen an infected port site after cholecystectomy. For some reason, they just never seem to get infected. Of course, lap appy is a different story.
  44. maxheadroom

    maxheadroom Rhinestone Cowboy Moderator

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    A few years ago a majority of the surgeons at one of the hospitals where I trained more or less staged a revolt after 12 months of US Surgical exclusive contract with the hospital. They started booking almost every case at the competing, crappier hospital that had Ethicon. The US Surgical exclusive contract was canceled within two months.
  45. Thanatos

    Thanatos Senior Member

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    I'm a big fan of a running subcuticular closure without knots for all port incisions. I take a bite about 2mm away from the apex and make the needle tip come out right in the middle of the apex inside the wound. Then I take a bite (or two) on each side then come out 2mm through the skin at the other end. I leave tails on each end and give them a little pull while I put dermabond on, then cut the tails flush with the skin.

    I like it because its super fast, for a 5mm port if you only take one bite on each side you can do this in like 20 seconds. If you take small bites near the apex to start with your corners always lay flat and you don't have to worry about burying a knot or the damn thing ****ing up your corner.

    I'm convinced this is easiest, even the students can do this with descent results first time around. Worse case scenario you can always pull your tails tight, lay on some glue, and pinch a gaped corner with the pickups while it dries to fix a screw up.

    For the record I have not had one of these fall apart....yet.
  46. SLUser11

    SLUser11 CRS

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    Just to play devil's advocate, it takes about 20 seconds to do a single buried subcuticular stitch, and dermabond isn't needed....corners don't really get messed up in a situation like that. Many would argue that if you're going to use dermabond, you can just pinch the wound together with your fingers.

    That being said, you've illustrated the fact that there are a million different ways to close skin. If there was one way that worked better than the others, perhaps there wouldn't be so much variability.
  47. southernIM

    southernIM

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    Yeah for 5's if using dermabond...why not just pinch them shut ( with your fingers or Adsons) and glue
  48. Thanatos

    Thanatos Senior Member

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    I think the stitch brings the edges together a little better than just pinching it, especially in the rare thin person. I agree you can throw a single stitch just as well and have done it that way, I just personally think the running without knots is easier (for me anyway, and certainly for the students).

    Any day now NOTES will make this discussion obsolete anyway when we take out the appendix through the ear or something.
  49. illixir

    illixir One

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    I think the running stitch is easier, or harder to mess up, the single stitch has to be good on both sides. I have always only seen a running subcuticular for the umbilical site, not sure if we do much larger incisions there here, they're prob 3x the port length, we use only open Hasson.
  50. SLUser11

    SLUser11 CRS

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    I actually prefer to extract my specimens through the left ear, but several of my colleagues prefer the right ear. I think it depends on where you trained.

    On another note, call me old fashioned, but I still suture the ear shut at the end of the case...
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